Health Care Provider Hormonal Recommendations for Treatment of Menstrual Cycle-related Problems - A Vignette-based Study

Background: Combined hormonal contraceptives (CHC) are recommended for “non-contraceptive benefits” for menstrual cycle-related problems. But no evidence-based consensus exists. Our purpose was to assess the clinical choices of health care providers (HCP: pharmacists, physicians, nurses) for menstrual cycle-related scenarios.

Methods: A 1-page questionnaire was provided to continuing professional education attendees at events across Canada. They suggested treatments for four common clinical scenarios each involving a different menstrual cycle-related problem. Each case was followed by five to six choices. All potential options included CHC and cyclic progesterone (P4) or medroxyprogesterone (MPA); HCP could choose multiple options.

Results: CHC was recommended by 84% of HCP for at least one of four scenarios; 64% chose cyclic P4/MPA at least once. For teenage menorrhagia, 63% chose CHC, 23% cyclic P4/MPA and only 31% ibuprofen. For the 35 year-old smoker with polycystic ovary syndrome (PCOS), 55% discontinued CHC, but 22% suggested switching to higher-dose anti-androgen CHC; 23% chose cyclic MPA, 32% spironolactone and 14% metformin. For a premenopausal fragility fracture, 34% recommended CHC and only 5% cyclic MPA; 17% chose a contraindicated aminobisphosphonate. For perimenopausal VMS, 10% chose CHC, 34% cyclic P4, 21% cyclic MPA.

Conclusion: There are significant variations among HCP disciplines for treatment of menstrual cycle-related problems. Contraindications and disadvantages of CHC-based therapies in these scenarios seem to not be recognized by HCP. Evidences for progesterone-based therapies have not been translated into current clinical practice. Few HCP suggested evidence-based non-hormonal treatments. Efforts are needed to translate research-based, physiological menstrual cycle treatments into safe and effective clinical practice.